Common Back Problems in Mature Athletes

Rob Johnson, MD, FACSM, CAQ Professor, Department of Family Medicine and Community Health, University of Minnesota Team Physician, University of Minnesota Athletics Director Emeritus, Sports Medicine Fellowship Minneapolis, MN

I have no disclosures or conflicts of interest

Objectives

• Identify common back problems of the “mature” athlete

• Review common clinical presentations of these conditions

• Summarize treatment options • Outline “return to activity” strategies

Incidence of back conditions

• 65% lifetime incidence of “low back pain”

• 26% US occurrence in last 3 months

• Direct and indirect costs $1,000,000,000 per year

The Aging Spine

• Development of degenerative discogenic changes

• Bone mass reduction

Does sports activity matter?

Lundin O, Hellstrom M, Nilsson I, Sward L: Back pain and radiologic changes in the thoracolumbar spine of athletes. A long-term follow up. Scan J Med Sci Sports 2001;11:103-109

N=134 former top athletes (wrestling, gym, soccer, tennis) compared to 28 non-athlete controls

Results: Significantly more x-ray abnormalities among athletes Frequency of back pain same as control

Does sports activity matter?

Schmitt H, Dubljanin E, Schneider S, Schiltenwolf M: Radiographic changes in the lumbar spine in former elite athletes. Spine 2004; 29:2554-2559

Subjects: Athlete from various track and field disciplines Results: Shot putters, discus throwers, and javelin throwers had

more osteophytes, radiographically, than runners No differences in limitation of daily activities

Does sports activity matter

Videman T, Sarna S, Battie M, Koskinen S, Gill K, Paananen H, Gibbons L: The long-term effects of physical loading and exercise lifestyles on back-related symptoms, disability, and spinal pathology among men. Spine 1995; 20:699-709

Studied long-term effects of physical activity on back pain in former athletes

Results: Odds ratios for back pain lower in athletes than control subjects MRI comparisons Weight lifting associated with greater degeneration throughout

entire lumbar spine Soccer associated with degeneration in lower lumbar region Runners showed no signs of accelerated disc degeneration

Does sports activity matter?

No studies comparing rates of symptomatic stenosis in athletic population to nonathletic group

However… Healy JF, Healy BB, Wong WH, et al. Cervical and lumbar MRI in asymptomatic oldermale

lifelong athletes: frequency of degenerative findings. J Comput Assist Tomogr 1996;20(1):107–12.

15% incidence of degenerative changes of cervical and lumbar spine in asymptomatic high-level triathletes and handball players

Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imagingof the lumbar spine in people without back pain. N Engl J Med 1994;331(2):69 –73.

15% incidence of similar degenerative changes in asymptomatic elderly population

Imaging – Beware the consequences…

• 98 subjects (50 men, 48 women), ages 20-80; all asymptomatic 52% had at least single disk bulge 27% had protrusion 1% had extrusion 38% had abnormalities > 1 level

Jensen MC et al: Magnetic resonance imaging of the lumbar spine in people without back pain. New Engl J Med 1994;331 (2):69-73

Age and the Spine

• > age 50, 67% had more than one abnormality

• < age 50, 27% had more than one abnormality

Jensen MC et al: Magnetic resonance imaging of the lumbar spine in people without back pain. New Engl J Med 1994;331 (2):69-73

The Spine and Exercise

• 16% of those who exercised regularly had disk protrusions at L5-S1

• Sedentary had 4% prevalence of disk protrusions at L5-S1

Jensen MC et al: Magnetic resonance imaging of the lumbar spine in people without back pain. New Engl J Med 1994;331 (2):69-73

Other MRI findings in the Asymptomatic Spine

• Schmorl’s nodes 19% • Annular defects 14% • Facet arthropathy 8% • Spondylolysis 7% • Spondylolisthesis 7% • Central canal stenosis 7% • Foraminal stenosis 7% Jensen MC et al: Magnetic resonance imaging of the lumbar spine in people without

back pain. New Engl J Med 1994;331 (2):69-73

More Spine…

• N=67 who never had low back pain <60 years old:

• 20% had a disc herniation • One had spinal stenosis

>60 years old: • 36% had a disc herniation • 21% had spinal stenosis • All but one person had disc degeneration or disc

bulging Boden et al: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic

subjects: a prospective investigation. J Bone Joint Surg Am 1990;72(3):403-408

And even more spine…

• N=60 asymptomatic subjects 20-50 years old – 62-67% had disc bulges or protrusions – 32-33% had annular tears (high-signal-intensity

zones) – 18% had disc extrusions – Zero disc sequestrations – One subject had nerve root compression – End-plate abnormalities were found in 3-10% – Zero severe osteoarthritis

Weishaupt et al: MR imaging of the lumbar spine: prevalence of intervertebral disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joint in asymptomatic volunteers. Radiology 1998;209(3):661-666

Cervical and Lumbar Spine (asymptomatic active male population)

• N=19 active male athletes age 41-69 (ave.=53) 3 lumbar MRI’s normal 11 central protrusions (1 had 4 levels involved) 4 posterolateral disk herniations 1 severe spinal stenosis

4 cervical MRI’s normal 11 cervical foraminal stenosis 7 protruding osteophyte/disk complexes

Healy JF et al: Cervical and lumbar MRI in asymptomatic older male lifelong athletes: frequency of

degenerative findings. Journal of Computer Assisted Tomography. 1996;20(1):107-112

Degenerative Disc Disease

• Lumbar disc herniation in athletes – Associated with activities that combine flexion,

rotation, compression – Representative activities – football, wrestling,

hockey, dance, gymnastics, tennis, golf

• General population – Multifactorial

Disc Disease

• Axial Pain – Commonly presents as

acute onset pain, muscle spasm resulting in time lost from work and sport

• Radicular Pain – Characterized by

common dermatomal distribution of sensory and/or motor deficits

• Axial and Radicular Pain

Disc Disease

• History – Familiar signs and sx – “Red flag” signs (fever, weight loss , cancer hx)

• Exam – Nerve tension signs

• + SLR • + Crossed SLR • + Slump test

Disc Disease Treament

• Activity modification • Pain management

– Acetaminophen – NSAIDs, oral corticosteroids – Opiates – Gabapentin, pregabilin – Epidural corticosteroids

• Physical Therapy • Return to activity?

Unfortunately, none of these interventions alters the outcome!

Facet arthropathy

• Factors affecting the facet joint – Activities involving

• Extension

• Rotation

Facet arthropathy

• Clinical presentation – Pain may worsen with

back extension and rotation

– Impaired motion from pain avoidance behavior

– ± point tenderness – Sx variable

Facet Arthropathy Management

• Physical therapy to maintain neutral spine • Facet joint injections (corticosteroids)

– Mixed results (similar to normal saline) – Radiofrequency ablation of medial branch

nerves – No conclusive evidence for regenerative therapy

injections • Surgery? • Return to activity?

Lumbar spinal stenosis

• Incidence increases with age

• Foraminal stenosis due to disc space narrowing and osteophyte formation

Lumbar spinal stenosis

• Common symptoms – Dermatomal/myotomal distribution of

numbness, tingling, pain (foraminal) – Vague sx, polyradiculopathy (central stenosis) – 90% report unilateral or bilateral radicular sx – Usually exacerbated by lumbar extension;

improved with flexion – Neurogenic claudication

Lumbar spinal stenosis Evaluation

• X-rays – AP, lateral, flexion and extension views

• MRI

Lumbar spinal stenosis Treatment

• Medications – Analgesics – Neurogenic acting agents (gabapentin, pregabilin)

• Aerobic conditioning • Spinal stabilization, strengthening exercise • Epidural corticosteroid injections • Surgery (laminotomy, foraminotomy) • Return to activity?

Osteoporosis/Compression Fracture

• Weight bearing activity vs. non WB activity

• Hormonal influences

• Genetic influences

• Other lifestyle issues

Osteoporosis/Compression Fracture

• Osteoporosis can cause vague LBP (uncertain “pain generator”)

• Usual mechanism of compression fracture is susceptible individual bending forward or result of injury

Osteoporosis/Compression Fracture Treatment

• Analgesia • Bracing • PT • For persistent pain or further vertebral

collapse – Vertebroplasty – Kyphoplasty

• Return to activity?

Summary

• Disc disease

• Facet arthropathy

• Spinal stenosis

• Osteoporosis/Compression fracture

Borg-Stein J, Elson L, Brand E: The aging spine in sports. Clin Sports Med 2012;31:473-486